Comparative Analysis of the Influence of Perichondrium on Conjunctival Epithelialization on Conchal Cartilage Grafts in Eyelid Reconstruction: Experimental Study in Rabbits

Auricular skin-cartilage sandwich graft technique for full-thickness eyelid reconstruction

Full-thickness deficiency of eyelid tissues can result in coloboma or retraction or both. Here we report our initial experience on the use of auricular skin-cartilage sandwich graft technique for full-thickness eyelid deformities. Five patients (4-32 years) underwent the procedure. Patients with full-thickness eyelid deformity were included. Three patients were operated for large-sized coloboma and two for eyelid retraction. One patient had congenital, and four patients had acquired etiology. The following parameters were specifically assessed: correction of deformity, ocular surface problems, graft status, and epithelization of skin-cartilage graft. All the patients had a good correction of eyelid position, except one patient who had severe eyelid retraction (8 mm) at presentation. None of our patients had corneal erosion/defect, persistent ocular surface redness, or graft loss. The auricular skin-cartilage sandwich graft technique produces optimal results with no graft loss. Advancement of orbicularis muscle in between the auricular skin and cartilage grafts (sandwich technique) is an imperative step that leads to the survival of both grafts.

The addition of a conjunctival flap to a posterior lamella auricular cartilage graft: A technique to avoid corneal complications

PURPOSE

To present the benefits of the addition of a conjunctival flap when correcting lower eyelid retraction using an auricular cartilage graft.

METHODS

An auricular cartilage graft was obtained either from the concha o the scaphoid fossa. When preparing the receiving bed, the conjunctival incision was made 2 mm below the inferior margin of the lower eyelid tarsus, therefore, a conjunctival flap arising from the inferior border of the tarsus was obtained. The cartilage graft was placed in the lower eyelid. The inferior border of the graft was sutured to the retractors and conjunctiva using absorbable sutures. The superior border was sutured to the inferior tarsus, so that de conjunctival flap covered the superior portion of the graft.

RESULTS

Fourteen patients underwent the surgical technique. No corneal complications were observed in the early or late postoperative period. Donor site complications were not encountered.

CONCLUSIONS

The confection of a conjunctival flap that lines the superior portion of an auricular cartilage graft in the lower eyelid provides protection against corneal postoperative complications until the graft is epithelized.

Posterior lamellar reconstruction: a comprehensive review of the literature

The aim of the review is to describe the different techniques and materials available to reconstruct the tarsoconjunctival layer of the eyelid; to analyze their indications, advantages, and disadvantages. We searched the Cochrane, PubMed, and Ovid MEDLINE databases for English articles published between January 1990 and January 2017 using variations of the following key words: "posterior lamella," "eyelid reconstruction," "tarsoconjunctival," "flap," and "graft." Two reviewers checked the abstracts of the articles found to eliminate redundant or not relevant articles. The references of the identified articles were screened manually to include relevant works not found through the initial search. The search identified 174 articles. Only a few articles with a therapeutic level of evidence were found. Techniques for the posterior lamellar reconstruction can be categorized as local, regional, and distant flaps; tarsoconjunctival, heterotopic, homologous, and heterologous grafts. Several techniques and variations on the techniques exist to reconstruct the posterior lamella, and, for similar indications, there's no evidence of the primacy of one over the other. Defect size and location as well as patient features must guide the oculoplastic surgeon's choice. The use of biomaterials can avoid possible complications of the donor site.

Autologous tragal perichondrium transplantation: a novel approach for the management of painful bullous keratopathy

PURPOSE

To introduce autologous tragal perichondrium transplantation as a novel surgical modality for the management of intractable symptomatic bullous keratopathy.

METHODS

In three eyes of three patients with painful bullous keratopathy, autologous tragal perichondria were transplanted on the corneal surface with the human amniotic membrane transplanted above. We included an additional three eyes of three patients with painful bullous keratopathy who received amniotic membrane transplantation only to serve as controls. Clinical symptom outcomes were assessed using a visual analogue scale at postsurgical months 1, 3, 5, 7, and 9. In addition, transplanted tragal perichondrium and amniotic membrane complex tissue button obtained from one patient who underwent penetrating keratoplasty was evaluated by immunohistochemical analysis of CD34, vimentin, and alcian blue staining.

RESULTS

All three patients who underwent autologous tragal perichondrium and human amniotic membrane co-transplantation showed improvements in pain and tearing. However, all three patients in the control group experienced aggravation of tearing and no further improvement of pain 3 months after surgery. In addition, one patient in the control group developed premature degradation of the amniotic membrane. Histopathologic and immunohistochemical analysis showed intact surface epithelization and positive CD34, vimentin and alcian blue staining of transplanted tragal perichondria.

CONCLUSIONS

The tragal perichondrium has a high mechanical structural force and high potency due to well-organized epithelization and the presence of mesenchymal stem cells. Autologous tragal perichondrium transplantation may be an effective modality for the management of painful bullous keratopathy.

Reconstruction of total upper eyelid with prefabricated capsule-lined advancement flaps

BACKGROUND

A total upper eyelid defect is a rare problem that may result from tumor excision, trauma, or burns. Reconstruction of a total upper eyelid defect involves the reconstruction of 2 fundamental elements: anterior and posterior lamellae. Because an expander capsule looks like the palpebral conjunctiva with a moist, smooth, white glistening appearance, its use was investigated in the repair of total upper eyelid defects in rabbits.

METHODS

Sixty-six tissue expanders with the autogeneic conchal chondro-grafts were implanted into the foreheads of 66 rabbits. After 6 to 8 weeks, the sandwich-prefabricated advancement flaps were designed to reconstruct rectangular excisions of the upper eyelid. The cartilage was preliminarily inserted in a flap, formed by tissue expansion, and then transferred to an upper eyelid defect in the rabbit. Histopathology was evaluated at 3 days, 1 week, 2 weeks, 1 month, 2 months, and 4 months after reconstruction. The upper palpebral length was measured after 4 months of reconstruction as a 1-dimension reference point of flap contracture.

RESULTS

No edema, congestion, infection, corneal damage, or necrosis were observed during the reconstructions. Histopathologic studies revealed that the long-term capsule had a normal conjunctiva-like appearance with a stratified columnar epithelium. The average shortening, measured as the length between inner to outer canthal folds, was inconspicuous.

CONCLUSIONS

The expander capsule has the potential to act as an effective posterior lamellar substitute of eyelid in a rabbit model. Further studies should be undertaken to see if this represents a good model for a potential human clinical application.

Angular vessels as a new vascular pedicle of an island nasal chondromucosal flap: Anatomical study and clinical application

Successful eyelid reconstructions have been reported when using an axial nasal chondromucosal flap based on the dorsal nasal artery. The present study aimed to present a detailed anatomical description of the blood supply of the lateral nasal region and the angular artery, in order to propose the angular vessels as a new vascular pedicle for the island nasal chondromucosal flap. A total of 11 cadavers (22 hemi-faces) were examined. Observations with regard to the origin, course and distribution patterns of the angular artery were recorded. Based on the anatomical study findings, the angular vessels were proposed as a vascular source for the island nasal chondromucosal flap. Observations with regard to the varying origins of the angular artery were categorized into four types. The course of the angular artery along the nasojugal fold was constant. The angular artery branched off into the upper two-thirds of the lateral nasal region and anastomosed with the other vascular branches on the nasal dorsum. Clinically, reconstruction of a full-thickness defect of the lower eyelid was successfully performed by using this composite flap based on the angular vessels and an adjacent orbicularis oculi myocutaneous flap. Satisfactory esthetic outcomes were obtained for the donor and recipient sites. The angular artery is a good vascular source for an island nasal chondromucosal flap. The flap may be created safely and successfully in clinic. Island nasal chondromucosal flaps and nasolabial groove skin flaps based on the angular vessels may be designed simultaneously for use on full-thickness defects of the eyelid.